April 16th, 2009
Asthma, Cough, and Hoarseness: GERD or the Great Hoax?
For at least a decade, people suggested that GERD was more than just heartburn and regurgitation, that it might also account for all the wheezing, coughing, and throat clearing we were encountering in the clinic. This idea led to the notion that we should try high-dose acid-suppression therapy in these other “GERD” patients.
What has recently become clear, however, is that most of these patients don’t actually have GERD at all — and even when they do, empirical high-dose PPI therapy does not improve their non-reflux symptoms. The latest example of this comes from an RCT just published in the New England Journal of Medicine.
Despite this evidence, the belief that GERD accounts for a large proportion of airway symptoms seems tough to crack. What do you do when you encounter a patient whose cough, hoarseness, or wheezing has been blamed on GERD?
3 Responses to “Asthma, Cough, and Hoarseness: GERD or the Great Hoax?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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If a patient has symptoms highly suggested of GERD, I will give a trial of a PPI for four weeks. If this does not help, I would want to assess the cause behind the symptoms of retrosternal discomfort as well as those of wheeze and cough.
The problem is that everyone is fixated on acid-reflux when much GERD is secondary to acid or non-acid GERD. If you have microaspiration of stomach contents, even if there is no acid present, the enzymes and other material in the stomach matter can trigger reactive airways, lung tissue digestion, and significant inflammation.
In this type of GERD, you could not expect acid suppression to help much. It may be that fundoplication, prokinetics, of even positional regimens may help with non-acid reflux. The diagnosis is made with esophageal impedance studies that document electrical resistance changes as a bolus moves retrograde up the esophagus.
Acid isn’t everything.
I usually stop the PPI.
This concept has never had much basis. It is difficult to prove (even with pH monitoring correlated to symptoms, these tests cannot be carried out for extended periods of time). My experience is PPI’s rarely improve patient’s symptoms.
Post nasal drip, in the elderly associated with increased mucous viscosity, is by far the most common cause of chronic cough/throat clearing in my experience.